Presented by:- Dr Aquina Thulare Secretary-General: SA Medical Association

1. THE SOUTH AFRICAN MEDICAL ASSOCIATION (SAMA) Representative Professional Association for Doctors in South Africa Presentation to Parliamentary Portfolio Committee on Health 6 September 2005 Presented by:- Dr Aquina Thulare Secretary-General: SA Medical Association

2. Our Team Dr Aquina Thulare (SG/CEO) Dr Barney Selebano (Corporate Affairs) Dr M. Stoltz (Chair, W. Cape) Dr Oscar Setsubi (W. Cape Member) Ms Maliga Pillay (Legal) Uniting doctors for the health of the nation

3. Purpose of Presentation • THE ROLE OF SAMA • ITS FUNCTIONS AND ACTIVITIES • OPERATIONAL PROCESSES • CHALLENGES Uniting doctors for the health of the nation

4. Who is SAMA? • Professional Association – Sect 21 • Voluntary membership • 70% public and private doctors • Est. May 1998 – MASA & PDG/NAMDA • Total Unification – April 1999 • WMA member • Trade Union affiliated to COSATU Uniting doctors for the health of the nation

5. Mission To empower doctors to bring health to the nation Uniting doctors for the health of the nation

6. Objectives • Represent the doctors with authority and credibility • Promote integrity and image of profession • Develop medical leadership and skills • Provide doctors with knowledge • Promote medical education, research and academic excellence • Encourage involvement in health promotion and education • Influence the health care environment - promote improvements to health reform, policy and legislation • Act as the change agent in the health care transformation process Uniting doctors for the health of the nation

7. Activities SAMA believes doctors can positively influence medical practice by: • Anticipating and influencing health policy changes in the interest of the profession and the public • Promoting access to affordable, quality health care Uniting doctors for the health of the nation

8. SAMA STRUCTURE AND PROCESS SAMA BOARD OF DIRECTORS SAMA NATIONAL COUNCIL Health Policy Education, Science & Technology Committee for Public Sector Doctors Human Rights, Law &Ethics Private Practice Committees (GP’s and Specialists) Surgical Disciplines Consulting Disciplines 56 Speciality Groups 21 SAMA Branch

9. Core competencies of SAMA Private medical practice • Private practice policy, Develop diagnostic and procedure coding systems, Represent profession at CMS, BHF, RAF etc Public sector health matters and human resources • Labour advice, Collective Agreements, Disciplinary hearings, CCMA, Bargaining Councils, Grievances Health legislation, regulation and policies, human rights, medical law and ethics • Legislation, advice, drafts guidelines, stakeholder liaison, clinical protocols, co-ordinate standing committees Uniting doctors for the health of the nation

10. Education & Publishing Professional development and training FPD est. 1997 - registered private institution for higher education Publishing house HMPG, 25 000 subscribers, SAMJ, CME, etc. Uniting doctors for the health of the nation

11. Value Proposition Through its organizational structure and core competencies, SAMA is positioned to: • Represent the medical profession with integrity and credibility on interaction with government, the legislature and stakeholders • Influence the shaping of the healthcare environment to meet the needs and expectations of government and the SA population, at large, by promoting improvements to health reform, policy and regulation Uniting doctors for the health of the nation

12. SAMA supports and endorses the DoH’s vision for a health system for the future to: • “move towards a coherent, unified health system offering financial protection for all the population, in accessing a nationally affordable package of health care, at the time of need and • Away from a segmented and inequitable health system that burdens the country with unaffordable costs” Uniting doctors for the health of the nation

13. OPPORTUNITIES LEGISLATIVE FRAMEWORK AND RELATED DEVELOPMENTS Uniting doctors for the health of the nation

14. National Health Plan • Published in 1994 • Public document • Policy principles • Access • Affordability • Appropriateness • Regulatory principles • Cost of care • Facilities • National Health System • Private sector Uniting doctors for the health of the nation

15. Constitutional Framework Bill of Rights • Everyone has the right to haveaccessto • Health care services • Social security, including, if they are unable to support themselves and their dependants, appropriate social assistance • The state must take reasonable legislative steps within available resources to achieve a progressive realisation of rights • No one may be refused emergency medical treatment • Limitation of Rights Uniting doctors for the health of the nation

16. Legislative Framework • Regulation of medical schemes • Regulation of benefits • Regulation of MCOs and administrators • PMB’s Medical Schemes Act Council for Medical Schemes Uniting doctors for the health of the nation

17. Legislative Framework • Professional Boards • Training • Code of conduct • Continued professional development • “Protecting the public and guiding the profession” Medical Schemes Act Health Professions Act Health Professions Council Council for Medical Schemes Uniting doctors for the health of the nation

18. Legislative Framework • Medicines Control Council • Pricing of medicines (SEP) • Dispensing regulations Medicine and Related Substances Act Medical Schemes Act Health Professions Act Council for Medical Schemes Health Professions Council Uniting doctors for the health of the nation

19. Legislative Framework • Certificate of Need • National Health Reference Price List • Health Councils National Health Act Medicine and Related Substances Act Medical Schemes Act Health Professions Act Health Professions Council Council for Medical Schemes Uniting doctors for the health of the nation

20. Challenges • Definitions and Content • Legislations and Regulations • Implementation Uniting doctors for the health of the nation

21. Basic Health Care • Access to health care services = Basic healthcare package to be defined • Basic health care ≠ Primary health care Uniting doctors for the health of the nation

22. Quarternary Care Tertiary Care Basic healthcare package Secondary Care Primary Care Components of Basic health care Uniting doctors for the health of the nation

23. Stakeholders to decide…….. • Which portions of the secondary, tertiary and quaternary care will form part of the definition of the basic healthcare package • This will impact on SHI and basket of benefits in Basic Benefit Package • Low Income Medical Scheme • Prescribed Minimum Benefits Uniting doctors for the health of the nation

24. National Health Act • Provides uniformity in health services across the nation • Eradicates racial disparity in health care delivery • SAMA supports the objectives, in general • Certificate of Need (Sect 36) Uniting doctors for the health of the nation

25. Section 36 of NHA - CoN A person may not— • establish, construct, modify or acquire a health establishment or health agency; • increase the number of beds in, or acquire prescribed health technology at, a health establishment or health agency; • provide prescribed health services; or • continue to operate a health establishment or health agency after the expiration of 24 months from the date this Act took effect, without being in possession of a certificate of need. Uniting doctors for the health of the nation

26. Main concerns on the CoN • Criteria for regulations not clearly defined • Violates free market principles of supply and demand - S22 of SA Constitution • Family life affected and Economic uncertainty • Patient’s rights to choose a doctor • Maximum duration is only 20 years • CoN process internationally was not successful (need unique RSA solutions) Uniting doctors for the health of the nation

27. SAMA position on CoN • We accept the principle of a CoN to address “needs” • It is critical to identity “healthcare needs” • Interactive discussion with the DoH and healthcare stakeholders are imperative • Complementary processes- • To incentivise health care professionals to practise in underserved and/or remote areas • Comprehensive Human Resource Plan Uniting doctors for the health of the nation

28. SAMA suggests… Meeting between DoH and stakeholders : • Understanding of “Need” concept to be analysed • The public sector issues to be formally debated; • Incentives for retention of healthcare professional in SA - accurate economic and actuarial data required Uniting doctors for the health of the nation

29. Public sector issues • Shortage of medical personnel • Poor working conditions • Work overload • Insufficient career-pathing • Problems with Supervision • Salaries – scarce skills allowance, rural allowance, special incentives, RWOPS • Taxation of Public Sector Doctors - HPCSA, SAMA and MPS fees, and CPD fees for attending courses, congresses and seminars(major deterrent) Uniting doctors for the health of the nation

30. Reasons for leaving the public sectorSAMA Survey 2003

31. The Charter of the Public and Private Health Sectors of The Republic of South Africa(“the Charter”) released for public comment on 11 July 2005 Uniting doctors for the health of the nation

32. Draft Health Charter SAMA supports: • The need for health care system to be transformed at various levels • The notion of patient-centredness SAMA believes that health and medical professionals have a pivotal role to play in this regard Uniting doctors for the health of the nation

33. Key Transformation Areas • Access to Health Services • Equity in Health Services • Quality of Health Services • Black-Economic Empowerment Uniting doctors for the health of the nation

34. Access, Equity & Quality Critical success factors • Development of tools such as clinical guidelines and formularies • Retention of health care professionals in South Africa • Properly structured and sustainable Public Private Partnerships and Initiatives • Strengthening of Public Sector Uniting doctors for the health of the nation

35. Objective of PPP’s and PPI’s Should support the objectives of improving access to health care by: • Addressing the “needs” of patients in underserved and rural areas • Leveraging off spare capacity, where it exists, in the private sector • Incentivising health professionals to pursue careers in underserved areas by improving working conditions and the development of innovative business models Uniting doctors for the health of the nation

36. PPP / PPI and CoN PPP’s could well contribute to meeting some of the objectives of the proposed “Certificate of Need” through: • Improving access to, and distribution of, healthcare to all patients • Addressing the “needs” of underserved and rural areas through interactive engagement with the DoH • Cost containment within the public sector through PPP’s with the private sector e.g. utilization of health technologies • Provision of highly specialized services to the public sector. This could also strengthen training capacity at all levels within the public sector • Retaining health professionals in underserved areas by improving working conditions Uniting doctors for the health of the nation

37. PPP’s / PPI’s Successes • PPP’s have already been successfully implemented between the SA Society of Ophthalmology and Government in the provision of health services for the removal of cataracts • Similar developments between other Specialist Groups affiliated to SAMA are indeed possible. Uniting doctors for the health of the nation

38. BEE Challenges in the Charter To meet BEE equity objectives for the medical profession will require a different approach, because: • Output of qualified black doctors including specialists in historically advantaged institutions-inadequate • Transformation of the human resources within the professions is almost totally dependent upon the degree of transformation at the various universities, both at under- and post graduate level. • Need to increase number of institutions geared towards increasing numbers of black healthcare professionals Uniting doctors for the health of the nation

39. BEE Challenges Interactive engagement process between DoH, HPCSA, Medical Universities, other relevant Academic Institutions as well as SAMA and other professional Associations is required. Uniting doctors for the health of the nation

41. OTHER HEALTH POLICYISSUES Uniting doctors for the health of the nation

42. Health Professions Act • There is improved communication with MDB and HPCSA • Transgression of ethical rules and policies • Challenges • Ownership of practices by non-medical • Employment of doctors by corporates (except for emergency units) • Undesirable Business Practices Committee to deal with applications Uniting doctors for the health of the nation

43. Medicines and Related Substance Act Dispensing Regulations • Constitutional Court (regrettable) • Unanswered questions : - • Regulations not yet amended • Licences renewal in 3 years • Ongoing annual fees of R800.00 • Discursive argumentation: Funders and pharmaceutical companies act as “watchdog” – ultra vires? Uniting doctors for the health of the nation

44. Medicines and Related Substances Act Pricing Regulations • Intention of affordable medicines supported • Presentation made to Pricing Committee; • Need for Private practice sustainability • Ongoing problems: • Uncertainty since Constitutional Court case pending • “Threats” by funders to charge per pricing regulation which are invalid Uniting doctors for the health of the nation

45. Other Areas of Divergence • Schedule 5 Medicines- Mental Health Act versus Medicines and Related Substances Act • HP Act versus Medical Schemes Act versus Competition Act (DSP’s)

46. National Health Reference Price List (NHRPL) • NHA mandates MoH to determine a NRPL • Medical Schemes may determine their benefits; and • Service providers may determine their fees; but • These fees are not mandatory • List does not apply only to health professionals (but also to funders) Uniting doctors for the health of the nation

47. Questions iro NHRPL….. • Should it remain with CMS? • Does DoH have capacity? • Need for a separate Statutory body? • Can it be negotiated at a forum similar to a Bargaining Chamber ? Uniting doctors for the health of the nation

48. Medical Schemes Act and ICD-10 • Came into effect 1998 • Challenges: • Exact patient benefits iro PMB’s • No formal process to update Chronic Disease List • Standardized policy on DSP’s • Mandatory ICD-10 codes / Confidentiality • Section 53 Suspension of payments Uniting doctors for the health of the nation

49. Social Health Insurance • SHI takes REF process one step further • “Health tax” introduced • Commence 2008 ? • Concerns on SHI: • How many additional patients will benefit ? (7 million to 10 million) • Basic healthcare package to be determined • To be administered through current medical scheme infrastructure (high costs, capacity) • Interaction between public and private sector are vital • Poor will get poorer (no rebates) • Funding (actuarial) model versus service model Uniting doctors for the health of the nation

50. Risk Equalisation Fund • REF: Essentially, schemes with a poorer risk profile to be subsidised by others • Shadow process commenced 2005 • No exchange of monies • Fully implemented in 2006/7 Uniting doctors for the health of the nation